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Laparoscopic Cervicoisthmic Cerclage in Pregnancy

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Laparoscopic Cervicoisthmic Cerclage in Pregnancy September 1, 2005 • www.obgynnews.com Obstetrics 9 Laparoscopic Cervicoisthmic Cerclage in Pregnancy BY BETSY BATES and pregnancy loss. Laparoscopic cervicoisthmic cer- patients, while perinatologists have opted to observe Los Angeles Bureau clage during pregnancy is a novel and technically chal- others overnight. Some pregnancies are ongoing. lenging procedure. Ideally, it should be performed by 12 Fetal viability is carefully assessed before and after the U NIVERSAL C ITY, CALIF. — A significant number weeks’ gestation, at a point when the risk of spontaneous procedure, which initially took about 4 hours but, with of successful deliveries have occurred, and one patient has first trimester loss is minimal but there is still enough experience, has been reduced to about 90 minutes. delivered two babies, following laparoscopic cervicoisth- space to safely manipulate and work around the gravid Two losses have occurred, one the day following the pro- mic cerclage performed during pregnancy at the Univer- uterus, according to Dr. Brill. cedure and one at about 20 weeks’ gestation in a patient sity of Illinois, Chicago. Besides the threat of fetal loss, the risk of bleeding is with recurrent previous losses. In one early case, the la- Andrew I. Brill, M.D., professor of ob.gyn. and director considerable, so the surgical team must be prepared to paroscopic procedure was converted to laparotomy to con- of gynecologic endoscopy at the university, reported on quickly convert to conventional surgery. Morbid obesity trol bleeding when the underside of a harmonic scalpel more than a dozen cases at the annual abrupted a uterine vein. The procedure meeting of the Obstetrical and Gyneco- is performed under general anesthetic. logical Assembly of Southern California. RILL A cervical cup is placed into the vagi- The innovative laparoscopic proce- I. B na and up to the fornices to aid in lifting dure could offer hope of a minimally the uterus for skeletonization of the invasive alternative to a technically de- NDREW uterine vessels and placement of a Mer- . A R manding and often complicated ab- D siline ligature between the uterine vessels dominal surgery during pregnancy, in and the lower segment at the isthmus. patients for whom conventional vaginal A port is placed at the umbilicus for cerclage has failed or is not possible. the laparoscope. Two right and two left “These are patients who are quite paraumbilical ports are placed high and HOTOS COURTESY desperate, with a history of multiple P lateral, and one is placed at the midline losses despite repeated conventional The uterine vessels are skeletonized and The knotted Mersilene stitch has been suprapubic abutting the mons pubis. procedures,” Dr. Brill said. isolated from the lower uterine segment. placed, and the procedure is completed. Bipolar dissection and sharp dissection All the patients in his series had ex- are used to mobilize the uterine arter- perienced failure of conventional vaginal cerclages for cer- and the risk of significant abdominal adhesions should be ies well off the lower uterine segment. vical incompetence, and many had suffered repeated sec- viewed with caution, according to Dr. Brill. Using a right-angle dissector placed through the supra- ond-trimester losses. In some patients, previous cervical “This is a surgery where you know that if you make a pubic port, a Mersilene stitch is pulled from back to front procedures precluded placement of a vaginal cerclage. mistake, it’s over, and it’s a very rapid over,” he said. through windows created in the broad ligament and tied If such patients desire children, “There really is no sal- Nonetheless, the University of Illinois experience snugly around the isthmus of the uterus, insuring the su- vation but abdominal cervicoisthmic cerclage,” he ex- has been largely successful. Dr. Brill noted that the ex- ture remains flat against the posterior lower segment. plained. act numbers are being compiled for publication but that Throughout the procedure, precautions are taken Conventional abdominal cerclage typically requires an at least 10 healthy babies have been born following the against over-manipulating the uterus or causing vascular extended midline abdominal incision and a considerable procedure. injury. Cutting is performed with monopolar energy or hospital stay. Complications can include hemorrhage Some patients have undergone the procedure as out- blunt-tipped mechanical scissors. ■ Oral Misoprostol as Effective as Oxytocin Passive, Active Smoking Injection For Treating Postpartum Bleeding Both May Affect Fetus pregnant woman’s exposure to secondhand BY KAREN RICHARDSON line therapy if other injectables fail. oral misoprostol group had missing Acigarette smoke may be just as risky to the fe- Contributing Writer “You might not use it routinely for ac- hematocrit and hemoglobin values. tus as is active smoking, according to a pooled data tive management of the third stage to Of the secondary outcomes, 8.9% of reanalysis conducted by Stephen G. Grant, Ph.D., Q UEBEC C ITY — Oral misoprostol reduce or prevent blood loss, but if oxytocin patients had a hematocrit drop of the University of Pittsburgh. appears to be as effective as oxytocin bleeding occurs, then you can give of at least 30%, compared with 10.2% “This analysis shows not only that smoking dur- by injection in reducing blood loss at misoprostol either orally or rectally of patients in the misoprostol group. ing pregnancy causes genetic damage in the devel- delivery, but is associated with an in- with ease, and it’s easy to have it stored Blood loss that was greater than oping fetus that can be detected at birth, but also creased need for additional oxytocic in nursing stations or hospitals,” he 1,000 mL occurred in 2.3% of the oxy- that passive, or secondary, exposure causes just as drugs, according to a randomized, said. tocin group and 4.5% of the miso- much damage as active smoking, and it’s the same controlled trial presented in poster To assess efficacy of both agents, he prostol group. Additional uterotonics kind of damage,” Dr. Grant said in a statement. format at the annual meeting of the and his colleagues compared 311 were required in 40.5% of those in the In an interview, he said, “The women who go to Society of Obstetricians and Gynae- women given 400 mcg of oral miso- oxytocin group compared with 51.1% the trouble of quitting smoking feel they have taken cologists of Canada. prostol and 311 women who were of those in the oral misoprostol group. care of the problem. This is a cautionary exercise in “Oral misoprostol may be used to given intravenous oxytocin, 5 units Researchers noted that the number which we say women have to change their lifestyles reduce postpartum bleeding, particu- given after delivery of the anterior of patients receiving additional oxyto- in other ways” such as having their husbands quit larly in areas where injectable oxyto- shoulder of the fetus. Researchers cics was high in both groups, and this smoking and not going outside with their friends on cic drugs are unavailable,” reported looked at women who had cephalic was most likely due to the prevailing smoke breaks even if they don’t smoke themselves. lead investigator Thomas Baskett, presentation and delivered vaginally, routine at the hospital of giving an in- The analysis examined data from two contradic- M.B., professor of obstetrics and gy- between 2000 and 2003 at the IWK travenous infusion of oxytocin follow- tory studies on rates of mutation at the HPRT locus necology at Dalhousie University in Health Centre in Halifax. Those who ing the initial bolus dose at delivery. (a measure of in vivo mutagenesis) in newborn cord Halifax, Nova Scotia. had a multiple pregnancy, placenta Side effects of shivering and fever blood samples. Compared with samples from babies The synthetic PGE1 analogue has previa, abruptio placentae, coagula- were present only in patients in the who had not been exposed to smoke in utero, ex- the advantage of being a cheap, stable, tion abnormalities, cesarean section, misoprostol group at the dose used, but posed babies had significantly higher mutation rates. and orally administered uterotonic or severe asthma were excluded. were not clinically troublesome, the re- There were no significant differences in levels of in- agent. “The main application for this The primary outcome of at least a searchers noted. “Most of the trials duced mutation among children of exposed women is in developing countries, where they 10% drop in hematocrit at 24 hours’ that have found often upsetting shiver- (active smokers, women who had quit smoking don’t have personnel looking after post partum was not clinically or sta- ing were with 600 mcg, and our study when they learned they were pregnant, and women women who can inject, or where there tistically significantly different be- was with 400 mcg,” Dr. Baskett said in who were only passively exposed to smoke). is no equipment or oxytocics to do tween the groups, and occurred in 10 an interview. In the pooled data, the median HPRT mutation fre- so,” he said in an interview, adding of 291 (3.4%) of oxytocin patients, The study was conducted to sub- quencies for actively and passively smoking mothers that it might also have applications in compared with 11 of 294 (3.7%) in the stantiate that it is reasonable to use the were both 0.87. The median for those who had quit rural communities if injectable oxy- misoprostol group. 400-mcg dose if the local circum- smoking was 0.91, and for unexposed women, 0.60 tocics were not available. A total of 20 patients in the intra- stances and resources dictate that it be (BMC Pediatr. 2005;5:20 [Epub ahead of print]). Misoprostol has a role as second- venous oxytocin group and 17 in the used, he noted.
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